Ministry of Health and Family Welfare Government of india SELF DECLARATION FORM TO BE FILLED BY ALL INTERNATIONAL PASSENGERS (TO BE PRESENTED AT THE HEALTH & IMMIGRATION COUNTER) {All persons coming to India are required to fill up the Proforma in duplicate & submitting @ copy each o Health and Immigration Counter. Personal information Contact Address in india fr All Travellers: [=] Wame ofthe 7] House Number | ssenger | acs Z| Sireet/ilepe [a | seatno, 3 | reife | Soe (sted | No. | | a District/ City [7 [rassportno. I i =| Sate 5 | Nationality | Age inyears] eu lee 7 | Date of Arivad 7. | Residence Number I ork of Orin 0 ao pest orale 3 | Mobi number ™ journey ST (rmandatory file) destination emaihiD (Pasta) 2 Detas ofthe ctes/ countries visited in ast 28 days b. Do you presently have any ofthe following symptoms Fever Cour Respiratory Distress + Are you suffering from (Please indicate (Hypertenson, Diabetes, Bronchial Asthma, Cancer, Under Immunosuppressive therapy, Post- Transplant patients or any other illness), . | am not suppressing any relavant/ material facts and all the above stated information is correct tothe best of my knowledge. Non-dsclosure/ suppression of information may attract penal provisions. Signature ofthe passenger Incase you develop symptoms such as fever and cough within 28 days of leaving ths airport, restrict your outdoor ‘movement and contact MoHW'S 24 hours helpline number O11-23878046. Coll operator wil tell you whom to contact further, n the meanwhilekeep yourself solated in your house/ room.